Tüm alıştırma soruları

A 26-year-old woman comes to the office due to an 8-month history of an inability to conceive and absent menses. Menarche occurred at age 13, and her menses were previously regular, occurring every 28 days. Over the past 6 months, she has noticed increased hair growth on her face and chest, severe acne, and a deepening of her voice. She and her husband have been having unprotected intercourse regularly for the past year. She has no significant past medical history and takes no medications. Vital signs are temperature $37.1 \ ^\circ\text{C} \ (98.8 \ ^\circ\text{F})$, blood pressure $118/74 \text{ mmHg}$, pulse $78\text{/min}$, and respirations $16\text{/min}$. BMI is $24 \text{ kg/m}^2$. Physical examination reveals moderate acne on the cheeks and jawline, as well as coarse, dark terminal hair on the upper lip, chin, and periareolar areas. Pelvic examination reveals clitoromegaly. Bimanual examination shows a normal-sized uterus, but is otherwise limited due to patient guarding. A urine pregnancy test is negative. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of $1.9 \ \mu\text{U/mL}$ and a serum prolactin level of $11 \text{ ng/mL}$. Which of the following is the most appropriate next step in evaluation?

A 71-year-old resident of a long-term care facility is evaluated for a three-day history of frequent, watery bowel movements and mild abdominal cramping. The patient recently completed a 7-day course of oral ciprofloxacin for an uncomplicated urinary tract infection. Temperature is 37.7°C (99.9°F), blood pressure is 120/78 mmHg, and pulse is 90/min. Physical examination reveals mild, diffuse abdominal tenderness without rebound or guarding. Laboratory studies show a leukocyte count of 14,000/mm³. A stool nucleic acid amplification test is positive for Clostridioides difficile. Which of the following is the most appropriate pharmacotherapy for this patient?

During morning rounds, a patient who underwent right total knee arthroplasty $6$ days ago is evaluated for new-onset left leg pain and swelling. The patient, a female in her mid-sixties, has been receiving standard postoperative venous thromboembolism prophylaxis with subcutaneous unfractionated heparin since the day of surgery.

Vital signs are:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Heart rate: $92\text{/min}$
Blood pressure: $128/82\text{ mm Hg}$
Respiratory rate: $14\text{/min}$
Oxygen saturation: $97\%$ on room air

Physical examination reveals a swollen, erythematous, and tender left calf. The right surgical site is healing appropriately without signs of infection or excessive bleeding.

Laboratory studies are as follows:

Admission (Day 0):
Hemoglobin: $13.5\text{ g/dL}$
Platelet count: $280,000/\mu\text{L}$

Today (Day 6):
Hemoglobin: $12.8\text{ g/dL}$
Platelet count: $118,000/\mu\text{L}$
Leukocyte count: $7,200/\mu\text{L}$

Based on these findings, which of the following is the most appropriate next step in management?

A 42-year-old woman presents to the emergency department with a $12\text{-hour}$ history of severe, constant, epigastric pain that radiates to her back. The pain is associated with nausea and multiple episodes of nonbilious vomiting. She has no significant past medical history and does not consume alcohol. Her temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), pulse is $112\text{/min}$, and blood pressure is $132/84\text{ mm Hg}$. Physical examination reveals marked epigastric tenderness to deep palpation without rebound or guarding. Bowel sounds are decreased.

Laboratory studies show:
Leukocyte count: $11,500/\text{mm}^3$
Alanine aminotransferase (ALT): $185\text{ U/L}$
Aspartate aminotransferase (AST): $150\text{ U/L}$
Alkaline phosphatase: $110\text{ U/L}$
Total bilirubin: $1.0\text{ mg/dL}$
Lipase: $2,400\text{ U/L}$

A right upper quadrant ultrasound shows multiple gallstones in the gallbladder but a normal-caliber common bile duct without sonographic evidence of choledocholithiasis. Which of the following is the most appropriate next step in management?

A 28-year-old woman, gravida 1 para 0, at 18 weeks gestation, is evaluated in the intensive care unit. She was admitted three days ago for a severe exacerbation of pan-ulcerative colitis characterized by 15 bloody bowel movements daily. Upon admission, she was initiated on intravenous hydrocortisone, aggressive fluid resuscitation, and empiric intravenous ciprofloxacin and metronidazole. Blood cultures drawn on admission have since grown $Bacteroides fragilis$ that is susceptible to metronidazole. Today, the patient is lethargic. Her temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), pulse is $138\text{/min}$, blood pressure is $80/50\text{ mmHg}$, and respirations are $28\text{/min}$. Physical examination reveals a gravid uterus consistent with gestational age. The abdomen is markedly distended, tympanic, and exhibits diffuse rigidity with rebound tenderness. Laboratory studies show:

Leukocyte count: $26,000/\text{mm}^3$
Hemoglobin: $10.8\text{ g/dL}$

Arterial blood gas (room air):
pH: $7.18$
$\text{pCO}_2$: $42\text{ mmHg}$
$\text{HCO}_3^-$: $15\text{ mEq/L}$

An abdominal radiograph (performed with appropriate fetal shielding) demonstrates a continuous segment of transverse colon dilated to $9.5\text{ cm}$ with complete loss of haustral markings. No free intraperitoneal air is visualized.

Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old woman is assessed in the intensive care unit due to declining urine output. She underwent an exploratory laparotomy with small bowel resection for a strangulated internal hernia 24 hours ago. During the complex procedure, she received massive fluid resuscitation. Over the past four hours, her urine output via an indwelling Foley catheter has sequentially measured 15 mL, 12 mL, 10 mL, and 5 mL per hour. She is intubated, sedated, and receiving mechanical ventilation.

Her current vital signs include a temperature of 37.3°C (99.1°F), blood pressure of 105/65 mm Hg, and a heart rate of 118/min. Central venous pressure (CVP) is elevated at 15 mm Hg. Physical examination reveals a markedly firm and tensely distended abdomen. Review of the mechanical ventilator flow sheet demonstrates that peak inspiratory pressures have risen from 22 cm H2O to 42 cm H2O since the morning. Her serum creatinine has increased to 1.9 mg/dL from a preoperative baseline of 0.7 mg/dL.

Which of the following is the most appropriate next step in evaluating or managing this patient's condition?

A 74-year-old woman presents to the emergency department with a two-day history of a severe, right-sided throbbing headache, jaw pain when chewing, and a recent episode of sudden, painless, temporary loss of vision in her right eye. Laboratory studies show an erythrocyte sedimentation rate of $105 \text{ mm/hr}$ and a C-reactive protein level of $45 \text{ mg/L}$. Arrange the following clinical steps in the most appropriate chronological sequence for the diagnosis and management of this patient's condition.

A $68$-year-old man is evaluated in the intensive care unit on day $6$ of a prolonged admission for severe lobar pneumonia complicated by septic shock. He remains mechanically ventilated and is currently receiving enteral nutrition and low-dose norepinephrine. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $105/65$ mm Hg, and pulse is $92$/min. Physical examination shows no goiter or anterior neck masses. A routine metabolic panel obtained this morning is largely unremarkable. Thyroid function tests, which were ordered due to the patient's persistent lethargy during sedation weaning, reveal the following:

Prior to admission, the patient had no history of thyroid disease and was not taking any thyroid-related medications. Which of the following is the most appropriate next step in management regarding his thyroid function?

Match each patient's laboratory profile with the most likely underlying clinical etiology.

On the fourth day following an elective left total hip arthroplasty, a 68-year-old female develops a new fever. Her maximum temperature over the past shift was 38.6°C (101.5°F). She has a past medical history of hypertension and chronic obstructive pulmonary disease. The patient complains of increased urinary frequency, burning with urination, and vague suprapubic discomfort. An indwelling urethral catheter was utilized intraoperatively and discontinued 24 hours prior to this current evaluation. Her chronic mild cough remains at baseline with clear sputum. Physical examination demonstrates distant breath sounds bilaterally without focal crackles or wheezing. The surgical wound is well-approximated without erythema, fluctuance, or purulent drainage. Examination of the lower extremities reveals bilateral trace pitting edema without calf tenderness or asymmetric swelling. Vital signs include a blood pressure of 134/82 mmHg, pulse of 94/min, and respiratory rate of 16/min. Oxygen saturation is 95% on ambient air. Which of the following is the most appropriate next step in management?

Match each classic clinical presentation with its most likely esophageal diagnosis.

A 58-year-old man is evaluated in the hospital on the third day of admission for a catheter-related bloodstream infection. He initially presented to the emergency department with fever, chills, and hypotension during his outpatient hemodialysis session. At admission, blood cultures were drawn, his tunneled hemodialysis catheter was removed, and he was started on empiric intravenous vancomycin and cefepime. His past medical history is notable for end-stage renal disease, hypertension, and type 2 diabetes mellitus. His medical record indicates an allergy to amoxicillin, which caused a diffuse, non-pruritic maculopapular rash 15 years ago. Today, the patient is afebrile and hemodynamically stable. The blood cultures drawn at admission are growing *Staphylococcus aureus*.

Susceptibility testing results are as follows:

Which of the following is the most appropriate next step in antibiotic management?

Connect the following antineoplastic agents with their most characteristic adverse effect that dictates specific clinical monitoring or preventive management.

A 27-year-old woman presents to the clinic with an 8-month history of absent menses. She previously had regular 28-day menstrual cycles. Her body mass index is 22 kg/m $^2$ and physical examination is unremarkable. A urine $\beta$-hCG test performed in the office today is negative. Arrange the following steps in the classic diagnostic algorithm for secondary amenorrhea in the correct chronological sequence, from initial evaluation to final definitive testing.

A 42-year-old man presents to the clinic with a 3-month history of unintended weight loss, palpitations, excessive sweating, and frequent bowel movements. He also reports experiencing new-onset, intermittent frontal headaches over the same period. He has no significant past medical history and takes no medications. Blood pressure is $145/85 \text{ mm Hg}$ and pulse is $110/\text{min}$. Physical examination reveals a mild, diffuse enlargement of the thyroid gland without any palpable nodules. A fine resting tremor is present in both outstretched hands. Visual fields are full to confrontation.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $6.5 \text{ mIU/L}$ (Normal: $0.4 - 4.2 \text{ mIU/L}$)
Free thyroxine (T4): $3.2 \text{ ng/dL}$ (Normal: $0.8 - 1.8 \text{ ng/dL}$)
Free triiodothyronine (T3): $7.1 \text{ pg/mL}$ (Normal: $2.3 - 4.2 \text{ pg/mL}$)

Which of the following is the most appropriate next step in management?

A 45-year-old woman with a 15-year history of poorly controlled type 1 diabetes mellitus presents to the outpatient clinic with a three-month history of progressive early satiety, postprandial bloating, and intermittent vomiting of undigested food. Her vital signs are stable. Physical examination reveals a soft, non-tender abdomen with a distinct succussion splash on auscultation. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient's condition.

A 48-year-old woman is evaluated in the post-anesthesia care unit 90 minutes after undergoing a total thyroidectomy for a multinodular goiter. She reports sudden, progressive difficulty breathing and a sensation of severe pressure in her neck. Her voice has become hoarse and muffled. Vital signs are temperature 37.1°C (98.8°F), blood pressure 155/95 mm Hg, pulse 115/min, and respirations 28/min. Oxygen saturation is 89% on 4 L/min via nasal cannula. Physical examination reveals a tense, rapidly expanding swelling beneath the cervical incision and prominent inspiratory stridor. Oxygen by nonrebreather mask is initiated.

Arrange the following management steps in the most appropriate chronological order for this patient.

Hepatitis B virus (HBV) infection can present in various clinical phases, each characterized by a distinct serologic profile. Match each clinical status with its most representative hepatitis B serologic panel.

A 19-year-old man is brought to the emergency department due to abdominal pain, nausea, and vomiting for the past 2 days. He also reports increased thirst and frequent urination over the last week. His temperature is 37.1°C (98.8°F), pulse is 118/min, blood pressure is 90/60 mm Hg, and respirations are 26/min and deep. Mucous membranes are dry. Laboratory studies show:

Arterial blood gas shows a pH of 7.15.

Arrange the following steps in the optimal chronological sequence for the management of this patient's condition.

A 68-year-old man comes to the emergency department due to a 3-day history of worsening shortness of breath, increased cough, and a change in sputum color from clear to yellow-green. He has a history of severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%. His home medications include an albuterol inhaler, tiotropium, lisinopril, and carvedilol.

On presentation, his temperature is $38.0^\circ C$ ($100.4^\circ F$), blood pressure is 138/86 mm Hg, pulse is 98/min, and respirations are 24/min. Pulse oximetry is 92% on room air. Physical examination reveals a barrel chest, prolonged expiratory phase, and diffuse bilateral expiratory wheezes without crackles. Jugular venous pressure is 7 cm $H_2O$. There is trace bilateral lower extremity edema, which the patient states is his baseline.

Laboratory results show:
Leukocyte count: $11,500/mm^3$
B-type natriuretic peptide: 150 pg/mL

Arterial blood gas (room air):
pH: 7.36
$PaCO_2$: 52 mm Hg
$PaO_2$: 64 mm Hg
Calculated $HCO_3^-$: 28 mEq/L

A chest radiograph shows hyperinflated lungs with flattened diaphragms and no focal consolidations or pleural effusions. He is started on supplemental oxygen, nebulized albuterol and ipratropium, and systemic glucocorticoids.

Which of the following is the most appropriate additional step in management?